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76A642D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ��
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
i LOCALITY _
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
DESCRIPTION LOT NO. OWNER
�i MAIL
BLOCK TRACT 1 ADDRESS
/
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. ROUP MAP PROCESSED BY
BUILDINGS SK PG
CONTRACTOR '
ADDRESS CONNECTION DATA
_���� STATION DEPTH
CITY TEL. NO.
�y ` �-STATE UPPER
REGISTRATION NO. ! r d El COUNT
MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYP OONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO P.L. M.L.TO P.L... r
PUBLIC SEWER @ 55.00 , ,NO, a.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. JOB NO. O
PITS AND/OR DRAINFIELD @ 510.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. im
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIV[R EASEMENT RECORD. INSTR.N DATE 0
WORK TO HOUSE SEWER @ $3.00 v
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOU5E HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION I TOTAL FEE / CONNECTION CHARD FEE
-I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEME FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK 3-2 a 6
ADDRESS SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ElDRYW ELL [I
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO�ESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE f.� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_._ EE.VV//`"'���� SEEP,PIT(s) ❑ CESSPOOLS ❑
l I
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
L--o2 8 2 51 AUG 19 1 0 D 5.0 0- a